ADHD Questionnaire Patient Name *Phone Number *Email Address *InattentionHow often the do you makes careless mistakes/lacks attention to detail?OftenNot oftenHow often do you lack sustained attention in tasks or play activities?OftenNot oftenHow often are you a poor listener, even in the absence of obvious distraction?OftenNot oftenHow often do you fail to follow through on tasks and instructions?OftenNot oftenHow often do you have difficulty with organization, time management, and deadlines?OftenNot oftenHow often do you avoid tasks requiring sustained mental effort?OftenNot oftenHow often do you lose things necessary for tasks or activities?OftenNot oftenHow often are you easily distracted (including unrelated thoughts)?OftenNot oftenHow often do are you forgetful in daily activities?OftenNot oftenHow often do you fidget, tap hands, or squirms in seat?OftenNot oftenHow often do you leave your seat in situations when remaining seated is expected?OftenNot oftenHow often do you engage in excessive running/climbing or feelings of restlessness?OftenNot oftenHow often do you have difficulty with quiet, leisure activities?OftenNot oftenHow often are you on the go “on the go” acting as if “driven by a motor”?OftenNot oftenHow often do you unconsciously engage in excessive talking?OftenNot oftenHow often do you blurt out answers before questions are even completed?OftenNot oftenHow often do you have difficulty waiting turn?OftenNot oftenHow often do you interrupt or intrudes on others?OftenNot oftenHow often do jump from task to task and projects to project without completing the first?OftenNot oftenHow often do you have difficulty keeping your immediate surrounding clean and tidy?OftenNot oftenWhen you have a task that requires a lot of thought, how often do you avoid or delay getting started?OftenNot oftenHow often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?OftenNot oftenHow often do you have difficulty unwinding and relaxing when you have time to yourself?OftenNot oftenWhen you are in a conversation, how often do you find yourself finishing the sentences of the people you are talking to before they can finish them themselves?OftenNot oftenHow often do you find yourself talking too much when you are in social situations?OftenNot oftenHow often do you interrupt others when they are busy?OftenNot oftenWhen you have a task that requires a lot of thought, how often do you avoid or delay getting started?OftenNot oftenHow often do you procrastinate or postpone completing a required task to the last meeting?OftenNot oftenWhen did you have a Psychological Evaluation to confirm/rule out ADHD?What medication have you taken for ADHD in the past?Who prescribed this medication for you?What state did you live when the medication was prescribed for you? Submit
